Intranasal Lining Research Articles

Maxillary and total nasal reconstruction with a scapulo dorsal perforator flap

Facial gunshots injuries remain challenging and present functional and aesthetic problems. Such defects generally require composite tissue flaps for reconstruction. Rebuilding the palate and the maxilla is especially delicate because it requires reconstitution of the facial buttresses, and replacement of bony hard palate, based on occlusion, as well as the restoration of the thin intraoral and intranasal lining which normally constitute the soft palate. Various methods of reconstruction have been applied to this area in search of an ideal soft tissue and bone flap to restore the bony framework of the maxilla and palate while providing an internal lining. The scapula dorsal perforator flap is used in the case of a patient to successfully reconstruct the palate, the maxilla and the nasal pyramid in one stage. Free tissue transfer using thoracodorsal perforator flaps and scapula bone free flap have been already described in literature but never to perform the nasal pyramid reconstruction at the same time. Good functional and aesthetic results have been obtained in this case. This article also reviews, through the authors experience and literature, anatomical landmarks, indications, technical surgical tricks, advantages and disadvantages of this flap for palatal, maxillary and nose reconstruction.

Rare syringoid eccrine carcinoma of the upper lip and nasal base treated with resection and subsequent innovative reconstruction using an Abbé flap, turbinate flaps and three-stage forehead flap: a case report

BackgroundAlthough syringoma is a common benign tumour of the sudoriferous gland, there is also an extremely rare malignant form known as syringoid eccrine carcinoma (SEC). SEC usually exhibits slow growth with deep invasion and a frequent tendency to relapse. The treatment of choice is radical wide resection, which poses a difficult reconstructive problem, especially when the tumour is located in the centre of the face.Case presentationIn this case, a 70-year-old man was diagnosed with an SEC at the same location as a benign syringoma of the upper lip and nasal base that had undergone primary excision 7 years prior. Primary radical resection was performed with immediate Abbé flap reconstruction. Nevertheless, histology revealed positive margins, and 3 additional re-excisions were needed to achieve clear margins. Four months after the initial resection, the patient had undergone an innovative reconstruction technique including not only the Abbé flap but also a turbinate flap harvested with functional endonasal surgery and a three-stage forehead flap.ConclusionTo the best of our knowledge, this is the first case report of a suspect malignant transformation of a benign syringoma after 7 years. In addition, from oncoplastic and reconstructive points of view, the bilateral use of the turbinate flap for reconstructing the intranasal lining of the alar base is unusual, and the use of functional endonasal surgery in nasal reconstruction for reducing the risk of damaging the vascular supply of the flap is innovative.

Microvascular Reconstruction of Complex Nasal Defects: Case Reports and Review of the Literature.

Background:The area of nasal reconstruction can be challenging for the microsurgeon, as the nose is a complex structure. A 3-dimensional understanding of the organ is a prerequisite for a successful outcome. A combination of procedures is usually necessary to completely repair subtotal or total nasal defects. Contouring and secondary revisions may ensue to enhance the postoperative functional and aesthetic outcome of the reconstruction. This study aimed to present a review of the various methods of microvascular reconstruction for complex nasal defects based on the radial forearm flap (RFF).Methods:Two independent reviewers screened the literature on PubMed according to the inclusion criteria. The keywords for the search were “microvascular,” “nasal reconstruction,” and “free flaps in nasal reconstruction.” Articles on locoregional flap reconstruction, experimental animal studies, letters to the editors, non-English literature, and articles without full text were excluded from the study. The protocol is registered at the International Prospective Register of Systematic Reviews (CRD42019146447) under the umbrella of the National Institute for Health Research, and it is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.Results:Eighteen eligible studies were included in our articles. The infolding RFF, multiple skin paddles RFF, and prelaminated RFF were described. The results have been more than encouraging so far. Also, 3 clinical cases where the RFF provided intranasal lining and a forehead flap resurfaced the nose were presented.Conclusion:The RFF is a reliable technique for nasal reconstruction in expert hands.

Reconstruction of the Intranasal Lining.

Reconstruction of full-thickness nasal defects has been the subject of surgical inquiry and innovation for over 2,000 years. The replacement of the internal nasal lining is a critical feature of complex nasal reconstruction. Successful reconstruction can prevent cicatricial contraction, external distortion, and internal stenosis. An array of reconstructive possibilities has been described, including cutaneous, mucosal, and fascial options. The challenge to the reconstructive surgeon is to select the repair that maximizes internal stability, while maintaining a patent nasal airway, minimizing morbidity, and meeting patient expectations. This article reviews the options available for the reconstruction of the intranasal lining.

Primary intranasal lining injury cause, deformities, and treatment plan.

Nasal membranes may be injured by immune disease, infection, trauma, or cocaine. Destruction of the septum, vault and floor lining, external skin, upper lip, and adjacent structures follows. Lining injuries caused by cocaine, Wegener granulomatosis, primary syphilis, leishmaniasis, septorhinoplasty, septal cancer excision and irradiation, corrosive inhalation, and foreign body and iatrogenic intubation injury were reviewed. The site and degree of injury were correlated with presentation and anatomical and functional abnormality. Damage may be isolated to the septum, creating a septal fistula with loss of dorsal and tip support and modest collapse of the dorsum and tip with columellar retraction, or the injury may extend onto the vaults and floor, leading to circumferential scar contracture and severe nasal shortening and lip retraction. Progressive disease, infection, or iatrogenic injury increases soft-tissue damage, causing external skin contraction or full-thickness necrosis. Repair is determined by site, depth of injury, and clinical deformity--not cause. Lining necrosis and subsequent scar contraction, rather than structural compromise of the septum, are the primary causes of the severe deformity. If vault and floor lining injury is minimal, central support alone will restore dorsal and tip projection. Extensive loss requires release of scar contracture and replacement of the vault and floor lining with composite grafts, a microvascular flap, or hinge-over lining flaps, depending on the site and extent of injury. If the external skin is destroyed by scar or a full-thickness loss, a staged forehead flap will be required to resurface the nose.

Access and surgical approach to the isolated intranasal basal cell carcinoma

Primary intranasal basal cell carcinoma (BCC) is a rare tumour that presents a therapeutic challenge. Here we present two cases illustrating the lateral alarotomy to gain access to an isolated BCC involving only the intranasal lining. Successful intranasal access was achieved in both cases using the alarotomy technique. We also review other methods of repair for the isolated intranasal lining defect. The presentation of intranasal BCC purely as an isolated entity without cutaneous involvement is rare, and our surgical approach via alarotomy allows optimum visibility for tumour resection.

Secondary Closure of Small- to Medium-Size Palatal Defects After Ablative Surgery: Reappraisal of Reconstructive Techniques

Postoncologic reconstruction of the palate represents a major surgical challenge with respect to the thin intraoral and intranasal lining. Current reconstructive methods have ranged from obturative closure of the defect to microsurgical free tissue transfer. The final choice of treatment will be influenced by the size and location of the defect and surgeon experience. The goals of palate repair include optimizing palatal function for speech and eating, and avoiding dehiscence or postoperative fistulas. This study assessed the reliability of locoregional flaps for reconstructing maxillary defects. The present study described the surgical outcome of locoregional reconstruction of the hard and soft palate of 5 patients who had previously undergone tumor ablative surgery. They ranged in age from 19 to 64 years. None had received postoperative radiotherapy. The resultant surgical defects ranged in size from 2.5 to 12 cm(2). One patient experienced velopharyngeal insufficiency. In all cases, the palate was closed at the first attempt without complications. All flaps survived, and complete closure was obtained in these 4 patients. The patient with the velopharyngeal insufficiency experienced a significant improvement in articulation and swallowing function. The results of these 5 cases indicate that secondary locoregional flaps are a suitable alternative for palatal defect management. They have a high success rate and functional outcome. These secondary techniques can be reliably used to reconstruct small- to moderate-size palatal defects and represent a reliable reconstructive option with minimal morbidity.

Experience with a two-stage nasal reconstruction with the paramedian forehead flap

The unique anatomy of the nose combined with its aesthetic and functional importance makes its reconstruction a challenging but rewarding undertaking. The authors of this study present their experience in a two-stage nasal reconstruction with a paramedian forehead flap. The patient underwent reconstruction with a narrow pedicle to resurface the dorsum, and its distal wings covered the alae. He had a significant amount of residual intranasal lining and this was used for a pedicle flap. The reconstructed dorsum and nasal tip appeared bulky, and the soft triangle needed better definition after the second stage. The patient underwent two revisions with improvement in the projection, outline, and contour of the nose.

Total Nasal Reconstruction: A 6-Year Experience with the Three-Stage Forehead Flap Combined with the Septal Pivot Flap

Several different methods can be applied for repairing total nasal defects. Most of them are based on some common principles and techniques widely accepted and adopted by experienced surgeons. We have been using most of these techniques during the past two decades, however modifying and refining them several times. Our observations and sometimes disappointing experiences led to a concept that has remained unchanged for the past 6 years. It comprises three regular operative steps and sometimes a fourth surgical intervention for repair and refinement. First stage: Reconstruction of the septum using a bipedicled composite septal pivot flap (SPF), of the intranasal lining (INL), and the cover being established by elevating a full-thickness paramedian forehead flap (PMFF). Second stage: Re-elevation of the PMFF, thinning of its layers, and reconstruction of the subsurface framework using autogenous rib cartilage. Third stage: Division of the pedicle and minor corrections. We have been using this technique presented here since 2004 in nine consecutive patients with subtotal to supratotal nasal defects. Seven cases have been repaired completely by now and can be evaluated carefully. With this technique, results have significantly improved and have been stable to date.

Intranasal lining flaps

This article summarizes various surgical techniques useful in restoring intranasal lining required during reconstruction of full thickness nasal defects. Bipedical vestibular skin advancement flaps may be used for lining defects of the nostril that do not have a vertical height greater than 1.0 cm. Lining defects larger than 1.0 cm in vertical height are best repaired with an ipsilateral septal mucoperichondrial hinge flap. If this by itself is insufficient, a contralateral dorsal septal mucoperichondrial flap may be used to provide additional lining to the nasal sidewall and middle nasal vault. For full-thickness defects of the nasal tip or dorsum, some form of a septal composite chondromucosal pivotal flap may be necessary for lining the nasal passages. Inferior and middle turbinate mucoperiosteal flaps may on occasion supplement any of the septal mucosal flaps.

The Split Frontalis Muscle Flap Endoscopically Harvested for Nasal Soft-Tissue Defect Reconstruction

Sir: Postoncologic nasal reconstruction can be a challenge for the plastic surgeon who has to ensure tumor-free margins while recreating the normal appearance in an aesthetically pleasing fashion. The split frontalis muscle flap endoscopically harvested is a practical approach for reconstruction of nasal soft-tissue defects in patients with multiple skin carcinomas of the nasal root that require skeletization and in a selected group of patients in which local flaps or cheek and forehead skin flaps are not available.1 Hydrodissection with tumescent anesthesia is carried out. Then, the endoscopic tools are introduced through a mediofrontal skin access anteriorly to the hairline and two lateral access points in the frontotemporal region (Fig. 1).Fig. 1.: Preoperative appearance in a 73-year-old man affected by two carcinomas beside the root of the nose. In the preoperative markings, the skin access points and the muscle dissection area and its limits are shown.After accurate dissection of the skin flap, the frontalis muscle is detached from the periosteal plane forward to the superior margins of the eyebrow corrugator muscles and divided by a cephalic horizontal and two vertical craniocaudal incisions, turned over 180 degrees on its stalk, tunneled trough the glabella area, laid out on the recipient area, sutured to the healthy skin margins, and grafted with full-thickness skin (Fig. 2).Fig. 2.: The frontal muscle flap has been harvested, turned over on its stalk by 180 degrees, and tunneled trough the glabella.Twenty-nine patients underwent this procedure over a 6-year period. The most common histopathologic diagnosis was basal cell carcinoma. The mean size of the defect was 188 mm2 (range, 89 to 290 mm2). Four patients had partial cartilage resection repaired with conchal cartilage, and the intranasal lining was always preserved. In 22 patients (80 percent), the defects were limited to the upper two-thirds of the nasal pyramid, and the success rate was 100 percent. The mean follow-up was 17 months (range, 8 to 36 months). This technique is indicated in patients with multiple skin carcinomas of the root of the nose requiring skeletization; patients with multiple precancerous lesions or previous scars on the forehead area for which the traditional forehead skin flaps cannot be used; and patients who refuse evident scars on the forehead area or on the face, a condition that should not be underestimated. Therefore, the split frontalis muscle flap has the following advantages: its arc of rotation does not cause any distortion of the medial eyebrow, a probable condition using forehead skin flaps1,2; it is a single-stage procedure; and satisfactory morphologic-aesthetic results can be achieved, with minimal scarring at the donor site and stable outcomes.3 The split frontalis muscle flap endoscopically harvested can be considered an adequate and practical approach for nasal soft-tissue defect reconstruction. Luca Gentile, M.D. Michele Di Candia, M.D. Christian Pascone, M.D. Vincenzo Bucaria, M.D. Michele Pascone, M.D. Department of Plastic and Reconstructive Surgery Policlinico University Hospital Bari, Italy PATIENT CONSENT The patient provided written consent for the use of his image.

An Alternative Method for Reconstruction of Large Intranasal Lining Defects

To examine use of the paramedian forehead flap for intranasal lining. The medical records and photographs were reviewed for patients who underwent a nasal reconstruction involving a paramedian forehead flap used for internal lining. Three patients underwent this procedure. In all patients, the flap provided excellent intranasal lining. External incisions were acceptable in all the patients. The paramedian forehead flap may be used for internal lining of large intranasal defects. An external rhinoplasty approach facilitates reconstruction.

Reconstruction of Extensive Nasal Defects with Staged Bilateral Paramedian Forehead Flaps

Reconstruction of near-total and total nasal defects is technically challenging, particularly in patients with an extensive smoking history. One of the keys to a successful esthetic and functional reconstruction is the use of intranasal lining that is reliable and not susceptible to necrosis. Unlike mucosal flaps and skin turn-in flaps with a random blood supply, paramedian forehead flaps have an axial blood supply and are less likely to be adversely affected by a patient's smoking history. In this report, we describe the use of staged bilateral paramedian forehead flaps as an alternative technique for patients with isolated near-total or total nasal defects where local tissue is of insufficient quality or quantity for intranasal flap design. The use of staged bilateral forehead flaps can result in acceptable functional and esthetic outcomes in patients with extensive nasal defects.

The Path of Nasal Reconstruction: From Ancient India to the Present

Nasal reconstruction, first described over 2600 years ago in India, has undergone several modifications in its development. However, there is a misconception that this surgery began with the forehead flap repair, and the history of the subsequent two and a half millennia is poorly represented in most surgical texts. This article presents a review of the historical significance of nasal injuries in antiquity and the various technical developments along the path to modern nasal reconstruction, from ancient India through medieval Europe to modern England and America. Although written texts from 6th-century BC India through 16th-century AD Europe described pedicle flap repair of nasal defects, it was not until the late 18th century that the first written description of the forehead flap appeared. Forehead flap repair developed on an alternate pathway, being transmitted via an oral tradition, typically within families of craftsmen, at least as early as the 14th century. These ancient authors recognized the need for accurate flap design and sizing, donor site repair, precise tissue apposition, protection of the flap pedicle, hemostasis, deepithelialization of the wound, and replacement of intranasal lining. By appreciating ancient surgical techniques and examining the particular issues these procedures attempted to address, the surgeon will gain an additional and more detailed perspective of nasal reconstruction that will aid in providing excellent care to his patients.

Reconstruction de l’aile narinaire par lambeau nasogénien à pédicule supérieur de Burget : à propos de sept cas

Background The reconstitution of a nasal alar rim and lobule defect represent a difficult challenge in consideration of his situation, anatomy and function. This article describes the technique and the interest of the nasolabial flap when used to cover the entire alar subunit. Methods We present 7 cases of alar rim and lobule defect after skin cancer excision. In the series, there are two full-thickness with lining defect. The patients were reconstructed with a superiorly based nasolabial flap, according to the subunit principle as introduced by Burget. A free cartilage graft was used to restore structural support with marginal skin flaps were turned over for intranasal lining when necessary. Results The cosmetic and functional outcomes of each repair were judged from good to excellent by patients and surgeons. No case of flap infection or necrosis occurred. Conclusion The superiorly based nasolabial flap, describe by Burget, provides an excellent choice for cosmetic and functional reconstruction of the nasal alar defect.

The Thoracodorsal Artery Perforator-Scapular Osteocutaneous (TDAP-SOC) Flap for Reconstruction of Palatal and Maxillary Defects

Despite technical advances over the past 3 decades, subtotal, total, and extended total maxillectomy defects remain challenging reconstructive problems. In particular, postoncologic resection of the maxilla results in complex 3-dimensional defects of the midface, which cause severe functional and esthetic deformities. Such defects generally require composite tissue flaps for reconstruction. Rebuilding the palate and maxilla is especially challenging because it requires reconstitution of the facial buttresses, occlusion, replacement of bony hard palate, and the thin intraoral and intranasal lining which normally constitute the soft palate. Various methods of reconstruction have been applied to this area in search of an ideal soft tissue-bone flap to restore the bony framework of the maxilla and palate while providing an internal lining. Osteocutaneous and osteomuscular flaps such originating from the scapular, iliac, peroneal, and radial vascular systems have been attempted with good success. We devised an osteocutaneous flap based on the scapular vascular system, which provided bone and soft tissue to successfully reconstruct the palate and maxilla in 2 patients. The skin paddle received its blood supply from the major perforating vessels of the thoracodorsal artery, and the scapular bone was nourished by the angular vessels. Although free tissue transfer using thoracodorsal perforator flaps has been described, this flap has not been previously reported in the literature as an osteocutaneous tissue transfer. With the use of rigid fixation, excellent results have been obtained with this technique for palatal and maxillary reconstruction.

A 10-Year Experience in Nasal Reconstruction with the Three-Stage Forehead Flap

Because of its ideal color and texture, forehead skin is acknowledged as the best donor site with which to resurface the nose. However, all forehead flaps, regardless of their vascular pedicles, are thicker than normal nasal skin. Stiff and flat, they do not easily mold from a two-dimensional to a three-dimensional shape. Traditionally, the forehead is transferred in two stages. At the first stage, frontalis muscle and subcutaneous tissue are excised distally and the partially thinned flap is inset into the recipient site. At a second stage, 3 weeks later, the pedicle is divided. However, such soft-tissue "thinning" is limited, incomplete, and piecemeal. Flap necrosis and contour irregularities are especially common in smokers and in major nasal reconstructions. To overcome these problems, the technique of forehead flap transfer was modified. An extra operation was added between transfer and division.At the first stage, a full-thickness forehead flap is elevated with all its layers and is transposed without thinning except for the columellar inset. Primary cartilage grafts are placed if vascularized intranasal lining is present or restored. Importantly, at the first stage, skin grafts or a folded forehead flap can be used effectively for lining. A full-thickness skin graft will reliably survive when placed on a highly vascular bed. A full-thickness forehead flap can be folded to replace missing cover skin, with a distal extension, in continuity, to supply lining. At the second stage, 3 weeks later during an intermediate operation, the full-thickness forehead flap, now healed to its recipient bed, is physiologically delayed. Forehead skin with 3 to 4 mm of subcutaneous fat (nasal skin thickness) is elevated in the unscarred subcutaneous plane over the entire nasal inset, except for the columella. Skin grafts or folded flaps integrate into adjacent normal lining and can be completely separated from the overlying cover from which they were initially vascularized. If used, a folded forehead flap is incised free along the rim, completely separating the proximal cover flap from the distal lining extension. The underlying subcutaneous tissue, frontalis muscle, and any previously positioned cartilage grafts are now widely exposed, and excess soft tissue can be excised to carve an ideal subunit, rigid subsurface architecture. Previous primary cartilage grafts can be repositioned, sculpted, or augmented, if required. Delayed primary cartilage grafts can be placed to support lining created from a skin graft or a folded flap. The forehead cover skin (thin, supple, and conforming) is then replaced on the underlying rigid, recontoured, three-dimensional recipient bed. The pedicle is not transected. At a third stage, 3 weeks later (6 weeks after the initial transfer), the pedicle is divided. Over 10 years in 90 nasal reconstructions for partial and full-thickness defects, the three-stage forehead flap technique with an intermediate operation was used with primary and delayed primary grafts, and with intranasal lining flaps (n = 15), skin grafts (n = 11), folded forehead flaps (n = 3), turnover flaps (n = 5), prefabricated flaps (n = 4), and free flaps for lining (n = 2). Necrosis of the forehead flap did not occur. Late revisions were not required or were minor in partial defects. In full-thickness defects, a major revision and more than two minor revisions were performed in less than 5 percent of patients. Overall, the aesthetic results approached normal. The planned three-stage forehead flap technique of nasal repair with an intermediate operation (1) transfers subtle, conforming forehead skin of ideal thinness for cover, with little risk of necrosis; (2) uses primary and delayed primary grafts and permits modification of initial cartilage grafts to correct failures of design, malposition, or scar contraction before flap division; (3) creates an ideal, rigid subsurface framework of hard and soft tissue that is reflected through overlying skin and blends well into adjacent recipient tissues; (4) expands the application of lining techniques to include the use of skin grafts for lining at the first stage, or as a "salvage procedure" during the second stage, and also permits the aesthetic use of folded forehead flaps for lining; (5) ensures maximal blood supply and vascular safety to all nasal layers; (6) provides the surgeon with options to salvage reconstructive catastrophes; (7) improves the aesthetic result while decreasing the number and difficulty of revision operations and overall time for repair; and (8) emphasizes the interdependence of anatomy (cover, lining, and support) and provides insight into the nature of wound injury and repair in nasal reconstruction.